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Surgical Knot Tying Manual

Third Edition

Surgical Knot Tying Manual Richard F. Edlich, M.D., Ph.D.
Distinguished Professor of Plastic Surgery,
Third Edition Biomedical Engineering and Emergency Medicine
Founder of DeCamp Burn and Wound Healing Center
University of Virginia Health System
Director of Trauma Prevention, Education and Research
Trauma Specialists, LLP, Legacy Emanuel Hospital
Portland, Oregon
William B. Long III, M.D.
President and Medical Director, Trauma Specialists, LLP,
Legacy Emanuel Hospital
Portland, OR

forward
If this manual heightens only perceptibly students, nurses,
nurse practitioners, physician assistants, surgical residents
and surgeon’s interest in the biology of wound closure and infection,
the long years occupied in my search for improved methods of
wound management would more than fulfill my expectations.
However, another important purpose of this manual is to honor
my colleagues, who collaborated in our clinical and experimental
research investigations. It is a duteous pleasure to acknowledge the
great help that I have received from Dr. George T. Rodeheaver,
Distinguished Research Professor of Plastic Surgery, University of
Virginia Health System and Dr. John G. Thacker, Vice-Chairman
of the Department of Mechanical and Aerospace Engineering,
University of Virginia, who have made numerous scientific
contributions to my studies of wound closure. Dr. Thacker and
Dr. Rodeheaver are excellent teachers who provide the insight and
imagination that solve the most challenging problems. It is also
important to note that studies have been undertaken with gifted
surgeons in Trauma Specialist, LLP who have developed the only
verified Level I Trauma Center in the Pacific Northwest. Dr. William
B. Long III, President and Medical Director of Trauma Specialists,
LLP, of Legacy Emanuel Hospital has played an instrumental role in
evaluating the performance of surgical products for trauma care that
are used throughout the world.

Richard F. Edlich M.D., Ph.D.

Selection of Suture and Needle Products 86 XII. Slip Knot (S=S) 62 IX. Nonabsorbable Suture 5 2. Instrument-Tie Technique 1. Tying Techniques 34 1. Knot Breakage 31 3. Absorbable Suture 12 IV.table of contents I. Square Knot (1=1) 44 2. Suture Cutting Tissue 32 4. Components of a Knotted Suture Loop using either a Granny Knot Type or a Square Knot Type 22 V. Hand Tie 39 VII. Surgeon’s Knot Square (2=1) 52 3. Instrument Tie 37 2. References 87 . One-Hand Technique 1. Mechanical Performance 28 1. Mechanical Trauma 33 VI. Knot Slippage 30 2. Individualized Self-Instruction 1 II. Essential Elements 42 VIII. Square Knot (1=1) 78 XI. Scientific Basis for Selection of Sutures 4 1. Two-Hand Techniques 44 1. Square (1=1) 70 X. Introduction 2 III.

I. individualized self instruction

The root origin of the word education is educare or to anglicize it, edu-care. The meaning
of education, therefore, is to care for, to nourish, to cause to grow. This being their ultimate
responsibility, teachers of surgery should be the most responsive component of the instruction
system. Numerous other pressing clinical and administrative commitments, however, often
limit interactions with the medical students, nurses, nurse practitioners physician assistants,
surgical residents and surgeons. Consequently, learning difficulties may not be identified.
This manual was designed to be a self-instructional teaching aid for the medical student,
resident, and surgeon providing an individualized environment of learning. For convenience,
each page of this manual has wide margins to accommodate personal thoughts and further
clarification. This manual is bound in a ring binder so that it lies flat, a prerequisite for any
knot tying manual. The reader should take as little or as much time as needed to digest the
information and to develop the illustrated psychomotor skills. At the end of this instruction,
you should feel considerably more comfortable in understanding the science of tying surgical
knots. More importantly it is our hope that this manual will inspire, motivate, and encourage
creativity and self-direction in your study of the biology of wound repair and infection.

This Knot Tying Manual is available online at www.covidien.com/syneture.

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II. introduction

Through the ages, the tying of knots has played an important role in the life of man.1
Most of the ancient civilized nations, as well as savage tribes, were accomplished
rope makers. Because rope could have served few useful purposes unless it could be
attached to objects by knots, man’s conception of the rope and the knot must have
occurred concomitantly. Knotted ropes played many important roles in the ancient
world, being used in building bridges and in rigging ships.
Because rope and knots have been two of man’s most useful tools since the dawn
of history, it is not surprising that they also have symbolic and even magical
connotations. It was the custom of Roman brides to wear a girdle tied with a square
(reef) knot, which their husbands untied on their marriage night, as an omen of
prolific offspring. Moreover, it was believed that wounds healed more rapidly when
the bandages which bound them were tied with a square (reef) knot.
This mythology of knots may have contributed to some surgeon’s perception of
surgical knots more as an art form, than as a science. For those artisans, the use
of methods and materials for suturing is usually a matter of habit, guesswork, or
tradition.2 This approach to suturing has contributed to a growing concern that
the knot construction employed by many surgeons is not optimal and that they
2

3. Individualized Self Instruction

use faulty technique in tying knots, which is the weakest link in a tied surgical suture. When
the recommended configuration of a knot, ascertained by mechanical performance tests
was compared to those used by board-certified general surgeons, only 25% of the surgeons
correctly used the appropriate knot construction.3 Of the 25 gynecologists, mostly department
heads, who were polled about their knot tying technique, most were convinced they they
made square knots, even though their knot tying technique resulted in slipknots that became
untied.4 When a knotted suture fails to perform its functions, the consequences may be
disastrous. Massive bleeding may occur when the suture loop surrounding a vessel becomes
untied or breaks. Wound dehiscence or incisional hernia may follow knot disruption.
As with any master surgeon, he/she must understand the tools of his/her profession. The
linkage between a surgeon and surgical equipment is a closed kinematic chain in which
the surgeon’s power is converted into finely coordinated movements that result in wound
closure with the least possible scar and without infection. The ultimate goal of this linkage the
perfection of the surgical discipline. This manual has been written for medical students, nurses,
nurse practitioners physician assistants, surgical residents and surgeons who view themselves
as scientists cultivating and practicing the science of surgery.

3

Ideally. scientific basis for the selection of surgical sutures There are several different suture materials and needles that provide an accurate and secure approximation of the wound edges. the tissue configuration. and the biomechanical properties of the wound. 5 Important considerations in wound closure are the type of suture. A common theme of the many reportable investigations is that all biomaterials placed within the tissue damage the host defenses and invite infection. and the configuration of the suture loops. Those that maintain their tensile strength for longer than 4 . Measurements of the in vivo degradation of sutures separate them into two general classes. the choice of the suture material should be based on the biological interaction of the materials employed.6 Sutures that undergo rapid degradation in tissues. Because surgical needles have a proven role in spreading deadly blood borne viral infection. are considered absorbable sutures. losing their tensile strength within 60 days. Selection of a surgical suture material is based on its biologic interaction with the wound and its mechanical performance in vivo and in vitro. the surgeon must select surgical gloves that reduce the risk of accidental injuries during surgery. the tying technique. The tissue should be held in apposition until the tensile strength of the wound is sufficient to withstand stress. III.

but still had 30-40% of its original strength at the end of two years. Postlethwait7 measured the tensile strength of implanted nonabsorbable sutures during a period of two years. Sofsilk™ silk sutures are nonabsorbable. CT) can be classified according to their origin.. Silk lost approximately 50% of its tensile strength in one year and had no strength at the end of two years. Nonabsorbable sutures made from natural fibers are silk sutures. Nonabsorbable surgical sutures The nonabsorbable sutures of Covidien (formerly Tyco Healthcare.60 days are nonabsorbable sutures. This protein is derived from the domesticated silkworm species Bombyx mori of the family bombycidae. cotton and nylon) lose some tensile strength during this 60-day interval. The silk fibers are treated to remove the naturally-occurring sericin gum and braided sutures are available coated uniformly with a special wax mixture 5 . 1. This terminology is somewhat misleading because even some nonabsorbable sutures (i. Norwalk. non-mutagenic surgical sutures composed of natural proteinaceous silk fibers called fibroin. sterile. silk.e. Nylon lost approximately 25% of its original strength throughout the two-year observation period. Cotton lost 50% of its strength in six months.

Modern chemistry has developed a variety of synthetic fibers from polyamides (nylon). annealing. ease of passage through tissue. polyesters (Dacron™). A new polypropylene suture 6 . All polypropylenes begin with a base resin and then go through the following steps: extrusion. a synthetic linear polyolefin. polyolefins (polyethylene. Metallic Steel sutures are derived from monofilament stainless steel. relaxation) can dramatically influence the surface characteristics without altering its strength. polytetrafluoroethylene. to polybutester. and knot run-down properties. scientific basis for the selection of surgical sutures (cont’d) or silicone to reduce capillarity and to increase surface lubricity which enhances handling characteristics. Sofsilk™ sutures are available colored black with Logwood extract.. Biomechanical studies demonstrate that the manufacturing process (i. Polypropylene sutures (Surgipro™) that have a low coefficient of friction will facilitate knot rundown and suture passage through the tissue. drawing.e. III. polypropylene). and annealing. relaxation. Changes in the surface characteristics can facilitate knot construction of the suture. Polypropylene is a linear hydrocarbon polymer that consists of a strand of polypropylene. Each step in the process will influence the ultimate biomechanical performance of the suture.

polypropylene sutures encounter lower drag forces in tissue than nylon sutures.(Surgipro™ II) has been developed that has increased resistance to fraying during knot rundown. they are favored for the construction of interrupted percutaneous suture closures. Only nylon sutures are available both as monofilament and multifilament sutures (Surgilon™). These braided nylon sutures are relatively inert 7 . and orthopedic surgery. Nylon sutures are also available in a braided construction. accounting for their frequent use in continuous dermal and percutaneous suture closure. Polypropylene sutures are widely used in plastic. The pliability characteristics of these sutures permit good handling. making them ideal for use in continuous dermal and percutaneous suture closure. They exhibit a lower drag coefficient in tissue than nylon sutures. However. Monosof™ and Dermalon™ are monofilament sutures composed of the long-chain polyamide polymers Nylon 6 and Nylon 6. They have a high tensile strength and low tissue reactivity. Because nylon sutures are more pliable and easier to handle than polypropylene sutures. general. cardiovascular. Polypropylene sutures are extremely inert in tissue and have been found to retain tensile strength in tissues for a period as long as two years.6.

8 . Polyester sutures were the first synthetic braided suture material shown to last indefinitely in tissues. Because some surgeons prefer to tie sutures with a high coefficient of friction. scientific basis for the selection of surgical sutures (cont’d) in tissue and possess the same handling and knot construction characteristics as the natural fiber. thereby facilitating knot construction and passage through tissue. Polyester sutures (Surgidac™. III. while the surface lubricant for Surgidac™ is polybutylene adipate. a synthetic linear polyester derived from the reaction of a glycol and a dibasic acid. When the sutures were coated with a lubricant. This coating markedly reduced the suture’s coefficient of friction. polyester sutures gained wide acceptance in surgery. Their acceptance in surgery was initially limited because the suture had a high coefficient of friction that interfered with passage through tissue and with the construction of a knot. The polybutester suture (Novafil™) is a block copolymer that contains butylene terephthalate (84%) and polytetramethylene ether glycol terephthalate (16%). TiCron™) are comprised of fibers of polyethylene terephthalate. the Surgidac™ sutures are also available without a surface coating. silk sutures (Sofsilk™). The TiCron™ polyester sutures are coated with silicone.

9 they compared the cosmetic outcome of lower midline laparotomy scars using either nylon or polybutester suture for skin closure. and a total score was assessed in all patients at 18 months following surgery and compared by nonparametric statistical tests. Regardless of the suture material used. In a study by Trimbos et al. With the polybutester suture. A randomized clinical trial compared polybutester skin suture with that of nylon for lower midline laparotomy wounds in 50 women undergoing gynecologic surgery. its elasticity is superior to that of other sutures.8 This monofilament synthetic nonabsorbable suture exhibits distinct differences in elongation compared with other sutures. scar width. scar color. allowing the suture to return to its original length once the load is removed. low forces yield significantly greater elongation than that of the other sutures. the presence of cross-hatching marks. In addition. The wounds closed with polybutester suture were significantly less hypertrophic than those closed with nylon. and the total scar score. the lower part of the laparo-tomy scar showed an inferior cosmetic result compared with the upper part underneath the umbilicus for scar hypertrophy. Scar hypertrophy. scar width. The surgeons concluded that polybutester skin suture diminished the risk of 9 .Polybutester suture has unique performance characteristics that may be advantageous for wound closure.

standard wounds were created in the dorsum and abdomen of the animals and subjected to suture closure with either polybutester or nylon. and flexibility which made suturing quicker and easier.11 The coating is a poly- tribolate polymer that is composed of three compounds: gylcolide. lack of package memory. 10 . five and seven days to evaluate the impact of the sutures on the wounds. scientific basis for the selection of surgical sutures (cont’d) hypertrophic scar formation because of its special properties allowing it to adapt to changing tensions in the wound. Pinheiro et al. Increased closure tension of the skin in the midline region above the pubic bone may be caused by a relative immobility of the skin. e-caprolactone. The animals were sacrificed immediately. The clinical performance of polybutester suture has been enhanced by coating its surface with a unique absorbable polymer (Vascufil™). elasticity. They concluded that Novafil™ suture can be used safely on skin and mucosal wounds because it is less irritating to tissues than nylon. III. In 1997. Under general anesthesia.10 compared the performance of polybutester sutures to that of nylon sutures in 70 male and female rats in which they examined the clinical response of the skin in abdominal wall muscle to the use of these sutures. They found that polybutester produced some advantages such as strength. and 72 hours and at four. 12. 24.

coating the polybutester suture represents another major advance in surgical suture performance. and vascular tissue. The collagen sutures are derived from the serosal layer of bovine small intestine (gut).and poloxamer 188. Knot security with the Vascufil™ suture was achieved with only one more throw than with comparably sized. When this treatment of collagen sutures is limited. The plain gut and chromic gut sutures are composed of several plies that have been twisted 11 . Absorbable surgical sutures The absorbable sutures of Covidien are made from either collagen or synthetic polymers. it becomes chromic gut (Chromic Gut). 2. Coating the polybutester suture markedly reduces its drag forces in musculoaponeurotic. Suture materials treated in this way are called plain gut (Plain Gut). the result is a special form of chromic gut (Mild Gut) that is more susceptible to tissue absorption. uncoated polybutester sutures. This collagenous tissue is treated with an aldehyde solution. If the suture is additionally treated with chromium trioxide. On the basis of the results of our investigations. which cross-links and strengthens the suture and makes it more resistant to enzymatic degradation. which is more highly cross-linked than plain gut and more resistant to absorption. colonic.

this degradation is started by acid phosphatase. Because of the inherent rigidity of this homopolymer. In most locations. polyglycolic acid. these natural fiber absorbable sutures have a tendency to fray during knot construction. with leucine aminopeptidase playing a more important role later in the absorption period. machine ground. there is considerably more variability in their retention of tensile strength than is found with the synthetic absorbable sutures. First. III. which led to the development of the polyglycolic acid sutures (Dexon™ II. and polished. This homopolymer 12 . monofilament sutures produced from polyglycolic acid sutures are too stiff for surgical use. Dexon™ S).13 These sutures are produced from the homopolymer. Collagenase is also thought to contribute to the enzymatic degradation of these collagen sutures. Soon procedures were perfected for the synthesis of high molecular weight polyglycolic acid. Natural fiber absorbable sutures have several distinct disadvantages. scientific basis for the selection of surgical sutures (cont’d) slightly. yielding a relatively smooth surface that is monofilament-like in appearance. A search for a synthetic substitute for collagen sutures began in the 1960s. Salthouse and colleagues12 demonstrated that the mechanism by which gut reabsorbs is the result of sequential attacks by lysosomal enzymes. Second.

Glycolide provides for high initial tensile strength.14 Using comparable knot construction and 13 . and provides for prolonged tensile strength in tissue. Copolymers of glycolide and lactide were then synthesized to produce a Lactomer™ copolymer that is used to produce a new braided absorbable suture (Polysorb™). or tensile strength loss.13 The Lactomer™ copolymer consists of glycolide and lactide in a 9:1 ratio.13 Lactide has a slower and controlled rate of hydrolysis. Dexon™ S) degrade in an aqueous environment through hydrolysis of the ester linkage.can be used as a monofilament suture only in the finest size. The glycolide and lactide behaved differently when exposed to tissue hydrolysis. to reduce the coefficient of friction encountered in knot construction. this high molecular weight homo-polymer is extruded into thin filaments and braided. Consequently. but hydrolyses rapidly in tissue.13 The thin filaments of Dexon™ II are coated with Polycaprolate™. Dexon™ S is an uncoated braided suture. a copolymer of glycolide and epsilon-caprolactone. The polyglycolic acid sutures (Dexon™ II. The handling characteristics of the Polysorb™ sutures were found to be superior to those of the Polyglactin 910™ suture.

scientific basis for the selection of surgical sutures (cont’d) suture sizes. nearly 80% of the USP (United States Pharmacopoeia) tensile strength of these braided sutures remains. facilitating knot construction. At 14 days post-implantation. 14 . Absorption is essentially complete between days 56 and 70. The surfaces of the Polysorb™ sutures have been coated to decrease their coefficient of friction. the knot breaking strength for Polysorb™ sutures was significantly greater than that encountered by Polyglactin 910™ sutures. Approximately 30% of their USP tensile strength is retained at 21 days. We recently studied the determinants of suture extrusion following subcuticular closure by synthetic braided absorbable sutures in dermal skin wounds. III.15 Miniature swine were used to develop a model for studying suture extrusion. full-thickness skin incisions were made on each leg and the abdomen. Standard.14 The new Polysorb™ suture is coated with an absorbable mixture of caprolactone/glycolide copolymer and calcium steraroyl lactylate. In addition. the mean maximum knot rundown force encountered with the Polysorb™ sutures was significantly lower than that noted with the Polyglactin 910™ sutures.

30% vs. rather than by slippage with the least number of throws. Because the volume of suture material in the wound is obviously a critical determinant of suture extrusion. 4-throw knots in the second pig. wound dehiscence. The loops were secured with 3-throw knots in one pig.. 17% and 10%. 19%). subcuticular. respectively. The swine model reproduced the human clinical experience and suture extrusion. With Polysorb™ sutures.The wounds were closed with size 4/0 Polysorb™ or Coated Vicryl™ (Ethicon. Somerville. Inc. Because both braided absorbable suture materials are constructed with a secure surgical knot that fails only by breakage rather than slippage with a 3-throw surgeon’s knot square (2 =1 = 1). the 15 . and granuloma formation were all observed. the 5-throw surgeon’s knots had a higher cumulative incidence of suture extrusion than the 3-throw or 4- throw surgeon’s knot square. The cumulative incidence of suture extrusion over 5 weeks ranged from 10 to 33%. and 5-throw knots in the third pig. vertical loops secured with a surgeon’s knot. Each incision was closed with five interrupted. it is imperative that the surgeon construct a knot that fails by breakage. NJ) sutures. stitch abscess. This swine model offers an opportunity to study the parameters that influence suture extrusion. Coated Vicryl™ sutures had a higher mean cumulative incidence of suture extrusion than that of Polysorb™ sutures (31% vs.

Absorption of the trimethylene carbonate 16 . This monofilament suture retained approximately 50% of its breaking strength after implantation for 28 days. and still retained 25% of its original strength at 42 days. In contrast.16 Glycolide trimethylene carbonate is a linear copolymer made by reacting trimethylene carbonate and glycolide with diethylene glycol as an initiator and stannous chloride dihydrate as the catalyst. Finally. The strength of the monofilament synthetic absorbable suture. is maintained in vivo much longer than that of the braided synthetic absorbable suture. braided absorbable sutures retained only 1% to 5% of their strength at 28 days. but plays a key factor in precipitating suture extrusion. A monofilament absorbable suture (Maxon™) has been developed using trimethylene carbonate. III. Asymmetrical knot construction for dermal wound closure becomes an obvious invitation for suture extrusion. it is important to emphasize that the surgeon must always construct symmetrical surgical knots for dermal subcuticular skin closure in which the constructed knot is always positioned perpendicular to the linear wound incision. glycolide trimethylene carbonate (Maxon™). scientific basis for the selection of surgical sutures (cont’d) construction of additional throws with these sutures does not enhance the suture holding capacity.

Due to it’s construction. Caprosyn™ monofilament synthetic 17 . The latest innovation in the development of monofilament absorbable sutures has been the rapidly absorbing Caprosyn™ suture. Absorption is complete between 90 to 110 days. The Biosyn™ suture has many distinct advantages over the braided synthetic absorbable sutures. a terpolymer composed of glycolide (60%). Monofilament suture potentiates less bacterial infection than does the braided suture. this monofilament suture is significantly stronger than the braided synthetic absorbable suture over four weeks of implantation.17 First. Another innovation in the development of monofilament synthetic absorbable sutures has been the production of Glycomer 631. and dioxanone (14%) (Biosyn™). The handling characteristic of this monofilament suture is superior to the braided suture because it encounters lower drag forces in the tissue than does the braided suture. trimethylene carbonate (26%).suture is minimal until about the 60th day post-implantation and essentially complete within six months. It maintains approximately 75% of its USP tensile strength at two weeks and 40% at three weeks post- implant.

The rate of loss of suture mass of these two sutures was similar. strength loss. 18 . Prior to implantation. trimethylene carbonate. scientific basis for the selection of surgical sutures (cont’d) absorbable sutures are prepared from Polyglytone™ 6211 synthetic polyester which is composed of glycolide. We recently have compared the biomechanical performance of Caprosyn™ suture to that of Chromic Gut suture. and a minimum of 20-30% of knot strength at 10 days post implantation. All of its tensile strength is essentially lost by 21 days post implantation. as well as suture stiffness. As expected. suture loops of Caprosyn™ had a significantly greater mean breaking strength than suture loops of Chromic Gut. and lactide.18 The biomechanical performance studies included quantitative measurements of wound security. Three weeks after implantation of these absorbable suture loops. III. tissue drag. Implantation studies in animals indicate that Caprosyn™ suture retains a minimum of 50-60% USP knot strength at five days post implantation. mass loss. knot rundown. potentiation of infection. the sutures had no appreciable strength. Both Caprosyn™ and Chromic Gut sutures provided comparable resistance to wound disruption. Chromic Gut sutures potentiated significantly more infection than did the Caprosyn™ sutures. knot security. caprolactone.

Hydrolysis would be expected to proceed until small. being a proteinaceous substance. and removed from the implant site. The direct correlation of molecular weight and breaking strength of the synthetic absorbable sutures with both in vivo and in vitro incubation implies a similar mechanism of degradation. These biomechanical performance studies demonstrated the superior performance of synthetic Caprosyn™ sutures compared to Chromic Gut sutures and provide compelling evidence of why Caprosyn™ sutures are an excellent alternative to Chromic Gut sutures. then dissolved. it was not possible to reposition a two-throw granny knot. 19 . In the case of Chromic Gut sutures. is degraded primarily by the action of proteolytic enzymes. The smooth surface of the Caprosyn™ sutures encountered lower drag forces than did the Chromic Gut sutures. the chemical degradation of these sutures appears to be by non-enzymatic hydrolysis of the ester bonds. Furthermore. Because in vitro incubation provides only a buffered aqueous environment.The handling properties of the Caprosyn™ sutures were far superior to those of the Chromic Gut sutures. it was much easier to reposition the Caprosyn™ knotted sutures than the knotted Chromic Gut sutures. the gut or collagen suture. In contrast. soluble products are formed.

The terms rate of absorption and rate of tensile strength loss are not interchangeable. When considering an absorbable suture’s tensile strength in vivo. maintaining tissue approximation during healing. Although the rate of absorption is of some importance with regard to late suture complications. Some manufacturers persist in reporting maintenance of the tensile strength of their suture in tissue by referring only to the percentage retained of its initial tensile strength. the surgeon would have a valid clinical perspective to judge suture performance. rather than the percentage retained of its initial tensile strength. scientific basis for the selection of surgical sutures (cont’d) A distinction must be made between the rate of absorption and the rate of tensile strength loss of the suture material. If the manufacturers were to use these standards to describe maintenance of tensile strength. the rate of tensile strength loss is of much greater importance to the surgeon considering the primary function of the suture. III. such as sinus tracts and granulomas. we recommend that the manufacturer provide specific measurements of its holding capacity. making comparisons between 20 . The United States Pharmacopoeia (USP) has set tensile strength standards for synthetic absorbable suture material.

The need to use USP standards in reporting is particularly important when there are marked differences in the initial tensile strengths of the synthetic sutures. the initial tensile strength of Biosyn™ is 43% stronger than that of polydioxanone. 21 . the Biosyn™ suture is approximately 30% stronger.sutures difficult. At two weeks. For example.

First. Figure 1. the “ears” act as insurance that the loop will not become untied because of knot slippage. 22 . A throw is a wrapping or weaving of two strands. Second. the knot is composed of a number of throws snugged against each other.” or the side to which tension is applied during tying. components of a knotted suture loop using either a granny knot type or a square knot type The mode of operation of a suture is the creation of a loop of fixed perimeter secured in the geometry by a knot. the loop created by the knot maintains the approximation of the divided wound edges. The patient’s side is the portion of the knot adjacent to the loop. Finally.19 A tied suture has three components (Figure 1). The components of a tied suture. The doctor’s side of the knot is defined as the side of the knot with “ears. IV.

instead of once. the type of knot is judged to be square (reef). In a double throw. When the right “ear” and the loop of the two throws exit on the same side of the knot or parallel to each other. it is called a surgeon’s (friction) knot. A knot consisting of two double-wrap throws is appropriately called a double-double. When the knot is constructed by an initial double-wrap throw followed by a single throw. The configuration of a reversed surgeon’s knot is a single throw followed by a double-wrap throw. The configuration of the knot can be classified into two general types by the relationship between the knot “ears” and the loop (Figure 2). Figure 2. Each throw within a knot can either be a single or double throw. The configuration of surgical knots. The knot is considered a granny type if the right “ear” and the loop exit or cross different sides of the knot. the free end of a strand is passed twice. The tying of one or more additional throws completes the knot. the angle of this double-wrap throw is 720°. A single throw is formed by wrapping the two strands around each other so that the angle of the wrap equals 360°. 23 . around the other strand.

Figure 3. IV. the surgeon’s hands should be on each side and parallel to the suture loop 24 . When the surgeon’s hands lie on each side and parallel to the suture loop. the surgeon is merely wrapping one suture end (360°) around the other. with the suture ends exiting in opposite directions. (Figure 3). The direction of the applied tensions will be determined by the orientation of the suture loop in relation to that of the surgeon’s hands. the surgeon will apply tensions in a direction parallel to his/her forearms. components of a knotted suture loop (cont’d) When forming the first throw of either a square or granny knot. During knot construction. The surgeon will apply equal and opposing tension to the suture ends in the same planes.

which considerably limits changes in hand positions. with crossing and overlapping Figure 4. Conversely. As the surgeon’s hands move toward or away from his body. may be encountered when constructing knots in a deep body cavity.Tension will be applied to the farther suture end in a direction away from the surgeon. 25 . With each additional throw. permitting continuous visualization of knot construction. Orientation of the suture loop in a plane that is perpendicular to that of the surgeon’s forearms considerably complicates knot construction (Figure 4). This circumstance the hands is perpendicular to that of the suture loop. temporarily obscuring overlap (arrows) when the orientation of visualization of knot construction. After constructing the second throw of these knots. the surgeon must reverse the position of his/her hands. reversal of the position of the hands occurs in the same area. the movements of his right and left hands are in separate and distinct areas that do not cross. with an accompanying reversal of the position of the surgeon’s hand. the direction of the suture ends must be reversed. In this circumstance. The surgeon’s hands frequently of the surgeon’s hands. This relatively cumbersome hand position may interfere with the application of uniform opposing tensions to the suture ends. an invitation to the conversion of a square knot construction to a slip knot. and equal opposing force will be applied to the closer suture end in a direction toward the surgeon.

IV. the application of greater tension to one ”ear” than the other encourages construction of slip knots. Furthermore. a practice commonly encountered in tying deep-seated ligatures. When the tension (arrow) is reapplied in equal and opposing directions. the slip knot can be converted into a square knot. components of a knotted suture loop (cont’d) The granny knot and square knot can become a slip knot by making minor changes in the knot tying technique (Figure 5).20 Figure 5. 26 . Surgeons who do not reverse the position of their hands after forming each throw will construct slip knots.

It is. and all surgical knots can be defined unequivocally in this international language. The relationship between each throw being either crossed or parallel is signified by the symbols X or =. for example. Skin closure can be achieved by either percutaneous suture closure.21 The number of wraps for each throw is indicated by the appropriate Arabic number. perfectly obvious what is meant by 2x2x2. the square knot is designated 1=1. the first suture loop is constructed by using the single strand of the fixed suture end attached to the needle and a single strand of the free suture end. The presence of a slip knot construction is indicated by the letter S. In accordance with this code. Dermal or percutaneous suture closures are accomplished by either interrupted suture or a continuous suture closure technique. A simple code has been devised to describe a knot’s configuration (Figure 2). the knot of the last suture loop at the end of the continuous suture is constructed by a suture loop containing two strands and the single strand of the fixed suture end attached to the needle. Sutures remain the most common method of approximating the divided edges of skin. 27 . or a combination of both techniques. respectively. When utilizing a continuous suture. and the granny knot 1x1. This method of describing knots facilitates their identification and reproduction. the slip knots can usually be converted into either the square or granny knots. without giving the knot a name.When the tension is reapplied in equal and opposing directions. dermal suture closure. However.

te knot must be constructed as a square knot with a single strand and a suture loop. Construction of a square knot with accomplished by two separate strands of sutures. components of a knotted suture loop (cont’d) The first knot in a percutaneous and dermal suture closure usually has a square knot construction. The interrupted a single strand and suture loop. ends of the suture. In contrast. knots constructed with a suture loop have two suture strands that 28 . The configuration of a knot using a looped suture end and a fixed suture end attached to a needle is markedly different from the interrupted knotted suture loop in which knot construction is Figure 7. suture has a knot constructed by two single strands. At the end of a percutaneous and dermal closure. which add security to the knot by preventing untying during slippage. A square knot of an interrupted suture loop is formed by two single throws in which the right ear and loop come out in a position that is directly opposite to that of the left ear and loop. IV. The loop created by the knot maintains the apposition of tissue. A tied square knot suture has three components (Figure 6). The knot is composed of a number of throws secured against each other. The ears are the cut Figure 6. Construction of a square knot with two single strands.

The first knot in a continuous suture is constructed by two single strands. knot slippage will occur. knot security is achieved with square knot construction by using three or four throws. and the second knot is created by a single strand and a suture loop. resulting in wound dehiscence. Knots constructed by a double-strand suture loop and a single strand of the fixed suture end has three separate knot ears (Figure 7).are intertwined with the single strand of the fixed suture end. the interrupted percutaneous suture has two cut suture ends. The second step is the construction of additional throws until knot security is attained and slippage is prevented. knot construction involves two steps. The last suture loop and single strand involves at least five or six throws for knot security. The square knot is formed when the right ear and the loop of a two-throw knot exit on the same side of the knot and are parallel to each other. Knot construction with a suture loop predisposes the knot to suture slippage and requires additional throws for knot security. 29 . When knot construction is complete. When constructing the first interrupted suture loop with either absorbable or nonabsorbable monofilament sutures. If the trauma surgeon fails to construct secure knots at the beginning or the end of the laceration.22 Our biomechanical performance studies demonstrate that secure knot configuration of the interrupted suture loop created at the beginning of the wound is quite different from secure knot configuration of the knot constructed at the end of the wound. During wound closure. The first secures precise approximation of the wound edges by advancing either a one-throw or a two-throw knot to the wound surface. These differences in secure knot configurations are related to the types of suture strands used in knot construction.

24 Surgeons consider the handling characteristics of the suture to be one of the most important parameters in their selection of sutures. mechanical performance The mechanical performance of a suture is an important consideration in the selection of a surgical suture and can be measured by reproducible. The load elongation properties of a suture have important clinical implications. V. Surgeons evaluate the handling characteristics of sutures by constructing knots using manual and instrument-tie techniques. the suture should elongate under low loads to accommodate for the developing wound edema. it will elongate. but return to its original length after resolution of the edema. Ideally. exhibiting a resistance to creep. providing a preview of the ultimate 30 . Its coefficient of friction is a measure of the resistive forces encountered by contact of the surfaces of the suture material during knot construction. The knot breakage load for a secure knot that fails by breakage is a reliable measure of strength. During these tests. it should not elongate any further while continuously maintaining the load. the patient’s side of the knot. The surgeon prefers a suture which permits two-throw knots to be easily advanced to the wound edges. These biomechanical parameters play important roles in the clinical performance of the suture. Although it should exhibit an immediate stretch under low loads. biomechanical parameters. As the suture is subjected to stress.23 The suture’s stiffness reflects its resistance to bending. Strength is a key performance parameter that indicates the suture’s resistance to breakage. forces are applied to the divided ends of the suture loop.

31 . All knots slip to some degree regardless of the type of suture material. In contrast. For comparable sutures. 24 Knot rundown of the surgeon’s knot square (2=1) generates sufficient forces to break the knot. the mean knot rundown force for square knots is the greatest. The force required to advance the knot is called knot rundown force. surgeons recommend that the length of the knot ”ears” be 3mm to accommodate for any knot slippage. the cut ends (“ears”) of the knot must provide the additional material to compensate for the enlarged suture loop. In general. surgeons prefer to cut their dermal suture “ears” as they exit from the knot. however. 3 Dermal sutures are. an exception to this rule. suture cutting through tissues. the surgeon prefers to add one more throw to the two-throw knot so that it does not fail by slippage. and then the slip (S=S. the knotted suture fails by slippage. Because the “ears” of dermal suture knots may protrude through the divided skin edges. knot rundown of square (1=1). The magnitude of the knot rundown force is influenced considerably by the configuration of two-throw knots. Failure of the knotted suture loop may be the result of either knot slippage or breakage. When the amount of knot slippage exceeds the length of the cut “ears. When slippage is encountered. Once meticulous approximation of the wound edges is achieved. SxS) knots occurs by slippage. which results in untying of the knot.” the throws of the knot become untied.apposition of the wound edges. SxS) knots. Initially. followed by that for the granny (1x1) knots. It must be emphasized that knot security is achieved in a knot with “ears”with one more throw than in a comparable knot whose “ear” length is 3mm. and mechanical crushing of the suture by surgical instruments. granny (1x1) and slip (S=S.

incrementally greater forces are required for knot untying. moisture. The resulting knot. will become untied regardless of the suture material. suture diameter. knot type and final geometry. After a specified number of throws. With each additional throw. Knots of the granny type (crossed) usually exhibit more slippage than do knots with a square-type (parallel) construction. Consequently.20-23 32 . Another serious error often made by the inexperienced surgeon is not to change the position of his/her hands appropriately during construction of square and/or granny type knots. The careless surgeon who applies minimal tension (10% of knot break strength) to the “ears” of the knot constructs knots that fail by slippage. a sliding or slip knot.19 The amount of tension exerted by the surgeon on the “ears” of the knot significantly alters the degree of slippage. Knot slippage can be minimized by applying more tensions (80% of knot break strength) to the “ears” of the knot. The risk of forming a slip knot is greatest when tying one- hand knots and/or with deep seated ligatures. these additional throws offer no mechanical advantage and represent more foreign bodies in the wound that damage host defenses and resistance to infection. The degree to which a knot slips can be influenced by a variety of factors including the coefficient of friction of the suture material. The human element in knot tying has considerable influence on the magnitude of knot slippage. failure will occur by knot breakage. after which the knot breakage force will not be enhanced by the addition of more throws. knot slippage Knot slippage is counteracted by the frictional forces of the knots.

” The latter knot loading rate is often referred to as “the jerk at the end of the knot.19 The forces exerted on a tied suture are converted into shear forces.25 This relationship between the tensile strength of unknotted and knotted suture which is designated knot efficiency. is least with mono-filament and multifilament steel. The percentage loss of tensile strength.3 The tissue in which the suture is implanted also has considerable influence on the knot strength of suture. and the diameter of the suture. the site of disruption of the suture is almost always the knot. although only up to a certain limit. 33 .23 When a constant force is applied slowly to the knot “ears. type of suture material. the efficiency of the knot is enhanced with an increasing number of throws.” especially when the knotted suture breaks.” the knot breakage force is significantly greater than that for knots in which the same constant force is applied rapidly to the “ears. The force necessary to break knot breakage a knotted suture is lower than that required to break an untied suture made of the same material. The type of knot configuration that results in a secure knot that fails by breaking varies considerably with different suture material. In addition. as a result of tying a secure knot.When enough force is applied to the tied suture to result in breakage. the magnitude of knot breakage force is significantly influenced by the rate of application of forces to the “ears” of the knot. a progressive decline in knot breaking strength is noted after tissue implantation. In the case of absorbable sutures. by the knot configuration that break the knot. is described in the following equation: Knot efficiency (%) = tensile strength of a knotted suture tensile strength of unknotted suture Regardless of the type of suture material. The magnitude of force necessary to produce knot breakage is influenced by the configuration of the knotted suture loop.

As expected. peritoneum and then fat. the paramedian incision required the lowest forces to pull sutures through its sheaths. When the suture was passed lateral to the transition between the linea alba and the rectus sheath. Tera and °Aberg27 measured the magnitude of forces required for suture to tear through excised musculoaponeurotic layers of laparotomy incisions. When the wound edges were approximated by suture tied tightly around this aponeurotic muscle layer. The type of tissue has considerable influence on the magnitude of tissue force required to tear the suture through the tissue. the force required for sutures to tear through tissue changes during healing. the reduction in force needed for the suture to pull through this tissue persisted for two weeks. When they recorded the forces needed for sutures to tear through structures involved in the repair of inguinal hernia. Howes and Harvey26 reported that the forces required to tear gut sutures through canine fascia was the greatest followed by muscle. The rationale for this study was that the forces required to tear sutures through a musculoaponeurotic layer would provide a basis for the choice of a suture whose strength is at least as strong as the forces required to tear the suture through the tissue. the structures making up the conjoined tendon and Cooper’s ligament were the strongest and exhibited twice the resistance to suture tearing than those of the other structures. 34 . Using cadaver specimens 6 to 93 days after death. suture cutting Suture failure also may occur if the knotted suture loop cuts through the tissue. Aberg28 reported that the forces needed for sutures to tear through the aponeurotic muscle layer reduced significantly during the first week of healing. the force required to tear the suture through the tissue was greater than that for any other musculoaponeurotic layer tested.

Mechanical trauma to the suture by surgical instruments can also result in
suture failure. Nichols et al29 cautioned surgeons about the handling of
mechanical trauma
sutures by surgical instruments. They indicated that either the application of
clamps and forceps to the suture or rough handling of sutures could damage
and weaken them. Stamp et al30 incriminated the teeth in the needle holder
jaws as important causal factors of sutural damage. Compression of sutures
between the needle holder jaws with teeth produced morphologic changes in
sutures that resulted in a marked reduction in the suture breaking strength.
Similarly, the sharp edges of needle holder jaws without teeth can even crush
the suture and, thereby, decrease its strength.31 Finally application of large
compressive loads by pinching polypropylene sutures with DeBakey forceps
decreases the strength of the suture.32

35

VI. tying techniques

The surgeon may use an individual ligature (“free tie”) or a suture that is attached
to a needle or ligature reel. The length of a free tie or suture attached to a needle is
usually 18 inches. The longest strands of suture material are available on a reel or
spool. When the suture is attached to a needle or reel, there is a free end and a fixed
end; the fixed end is attached to either the needle or reel. The first throw of a knot
is accomplished by wrapping the free end either once or twice (surgeon’s) around
the fixed end. During practice, clamp one end of the suture with an instrument that
serves to represent either the needle or the reel, which is the fixed end of the suture.
Formation of each throw of a knot is accomplished in three steps. The first step
is the formation of a suture loop. In the second step, the free suture end is passed
through the suture loop to create a throw. The final step is to advance the throw
to the wound surface. For the first throw of a square, granny, and surgeon’s knot
square, for each additional throw the direction in which tension is applied to the
suture ends is reversed. The surgeon should construct a knot by carefully snugging
each throw tightly against another. The rate of applying tension to each throw
should be relatively slow.
For either the square knot or surgeon’s knot square, the direction in which the
free suture end is passed through the loop will be reversed for each additional
throw. If the free suture end is passed down through the first suture loop, it must
be passed up through the next suture loop. Reversal of the direction of passage of
the free suture end through the loops does not alter either the knot’s mechanical
performance or its configuration. It simply reverses the presentation of the knot
(Figure 8). For granny knots, the direction in which the free suture end is passed
36 through the loop is the same for each additional throw.

Figure 8. Square knot (1=1) (A) is formed by first
passing the free suture end up through the suture
loop to create the first throw. The second throw
is formed by passing the free suture end down
through the suture loop. Square knot (1=1) (B)
is formed by passing the free suture end down
through the suture loop to create the first throw.
The second throw is formed by passing the free
suture end up through the suture loop.

During surgery, knot construction involves two distinct steps. The
purpose of the first step is to secure precise approximation of the
wound edges by advancing either a one-throw or a two-throw knot to
the wound surface. Once the throw or throws contact the wound, the
surgeon will have a preview of the ultimate apposition of the wound
edges. Ideally, the knotted suture loop should reapproximate the
divided wound edges without strangulating the tissue encircled by the
suture loop. If there is some separation of the wound edges, the one-
throw or two-throw knot can be advanced to reduce the size of the
suture loop and thereby bring the wound edges closer together.
When the surgeon forms a double-wrap throw, the first throw of the
surgeon’s knot square (2=1) can maintain apposition of the wound
edged by “locking” or temporarily securing it in place by reversing
the direction of pull on its “ears.” The “locked” double throw is not
37

24 In contrast. The magnitude of knot breakage force is significantly influenced by the rate of application of forces to the knot. When constant force is applied slowly to the knot “ears. 9 The risk of tying slip knots can be obviated by applying tensions to both “ears” in horizontal planes parallel to the tissue surface. but will never reach knot security even with 5 throws. limiting the surgeon’s ability to secure meticulous coaptation of the wound edges. The second step in knot construction is the addition of a sufficient number of throws to the knot so that it does not fail by slippage. but this knot will not advance by slippage. VI. The magnitude of knot breakage force is always greater than that for knot slippage force of a comparable suture. two-throw square (1=1) or granny (1x1) knots can be advanced to the wound surface to secure precise wound edge apposition. These two-throw square (1=1) or granny (1x1) knots can be easily converted into their respective slip knots by applying tension to only one “ear” in a direction that is perpendicular to that of the tissue surface.” the knot breakage force is significantly greater than that for knots in which the same constant force is applied rapidly to the “ears. The addition of the second throw to the surgeon’s knot square (2=1) will provide additional resistance to wound disruption. Square (S=S) or granny (SxS) slip knots require lower knot rundown force for knot advancement than either the square (1=1) or granny (1x1) knots. tying techniques (cont’d) a reliable means of maintaining wound apposition because any tension applied to the “ears” from the patient’s side of the knot will unlock the knot.” 38 . ensuring optimal protection against wound dehiscence.

Instrument tying is accomplished primarily by the surgeon’s left hand. while the left hand loops the fixed suture end around the instrument. In contrast. Granny knots with more than two throws cannot be constructed by either the one-hand or two-hand technique. instrument tie Knot construction can be accomplished by either an instrument or hand tie. a square-type knot will develop. a granny-type knot will first result when the instrument is placed above the fixed suture end for the first throw and then below the fixed suture end for the second throw. Preferably. Initially the length of the fixed suture end held by the left hand is long (17 in. a circumstance not encountered in hand ties. without releasing hold of both suture ends. usually a needle holder.). the fixed suture end should be coiled into loops. the instrument tie is a reliable and easy method to produce multiple throw granny knots (1x1x1). 39 . which are held between the tips of the thumb and index finger. The position of the instrument in relation to the suture ends during knot construction will determine the type of knot. This assault can be avoided by shortening the length of the fixed suture end held by the left hand. When the instrument is placed above the fixed suture end during the first and second throws. By repeating this positioning. An instrument tie occurs by the formation of suture loop over an instrument. making it difficult to form knots without injuring the attending assistant. which holds the fixed suture end. The right hand holds the needle holder.

the parsimonious surgeon can complete 10 interrupted suture loops from one suture measuring 18 inches in length. When employing suture in the recesses of the body (e. is ideally suited for closing a wound which is subjected to weak tensions.) or during endoscopic surgery. The value of instrument ties has become readily apparent in special situations in which hand ties are impractical or impossible. In microsurgical procedures. When tying knots with an instrument. mouth. By pronating the wrist. 40 . This technique. The small and ring fingers are then withdrawn from the loop before coiling more suture.g. it is difficult to apply continuous tension to the suture ends. a loop forms around the grasped fingers. instruments can also form knots in sites to which the hand could never gain access. widening of the suture loop due to slippage is frequently encountered in wounds subjected to strong tension. instrument ties can be accomplished more rapidly and accurately than hand ties. By using this technique. The rasped suture can be easily lengthened by releasing the coils held between the tips of the thumb and index finger. an instrument tie provides the most reliable and easiest method of knot construction. etc. instrument tie (cont’d) This maneuver is accomplished by first grasping the fixed suture end with the small and ring fingers. vagina. In this circumstance. This feat would be impossible if the knots had been tied by hand. while it is being pinched between the tips of the index finger and thumb. and the top of the loop must again be grasped between the tips of the thumb and index fingers. however. while conserving considerably more suture. Consequently.

he/she constructs the knot predominantly with his/her left hand. The left hand continually holds the suture end until knot construction is complete. lets go. The student of surgery should master first the construction of square type knots because knot security can usually be achieved with fewer throws than the granny-type knots. In such cases.21 The additional foreign bodies required to form a secure granny knot. With the one-hand method. Using the two-hand technique. the right hand performs the major manipula-tion of the suture during formation of the loop. When the surgeon attempts to shorten the resultant enlarged loop by advancing the knot. An advantage of this 41 . The latter case is an invitation to needle puncture. An additional advantage of the two-hand tie is that the surgeon can apply continuous tension to the suture ends until a secure knot is formed. which forms a suture loop through which the free suture end is passed. Each technique has distinct advantages as well as drawbacks. The two-hand hand tie technique of knot tying is easier to learn than the one hand. Many right-handed surgeons prefer to manipulate the free end of the suture with their left and during two-hand ties. the right hand merely holds. and regrasps the free suture end. he/she will be passing either the needle or reel through the formed loop. requiring passage of another suture through the once punctured tissue. especially by the inexperienced surgeon. breakage of the suture may occur. it is often difficult to maintain tension on the suture ends during the formation of the knot and slippage of the first or second throws will be encountered. predisposes the wound to the development of infection.Hand tying of knots can be accomplished by either the two-hand or one-hand technique. In contrast. If the surgeon inadvertently manipulates the fixed suture end with his/her right hand. The hand-tying techniques illustrated in this manual are those used by right-handed individuals.

If one desired to learn to tie knots using the left hand to manipulate the free end of the suture. 42 . There are several important recommendations for selecting a knot tying technique. First. While exchanging suture ends between the hands forms a triangular-shaped suture loop. grasp the appropriate suture ends and form the suture loop. reverse the position of the hands after Figure 9. rather than the fixed suture end. allowing them to hold the needle holder in their right hand while they construct knots with their left hand. The other hand merely holds the mother suture end taut. Using the one-hand tie. through the suture loop. without exchanging suture ends between the hands. Second. study the illustrations in a mirror. hand tie technique is that a surgeon who ties his/her own knots by the two-hand technique during wound closure can hold the (cont’d) needle holder in his/her right hand during knot construction. one hand forms the suture loop while manipulating the free suture end. position the hands on each side of and parallel to the suture loop. Third pass the free suture end. Most surgeons prefer to manipulate the free suture end with their left hand. Standard format for illustrating the knot tying technique. it is an unnecessary step that wastes valuable time. Finally.

43 . there is retraction of the wound edges. after which a sufficient number of throws are added to the knot to ensure knot security.each additional throw. However. a slip knot has greater holding power than either a single-wrap or double-wrap throw. The tips of the distal phalanges of the thumb and index finger of the right hand grasp the suture end (black) exiting from the wound edge closer to the surgeon. slip. and surgeon’s knots using manual and instrument-tying techniques are illustrated in Sections VIII-X. with exposure of the underlying tissue. Because the surgeon usually passes the needle swaged to a suture toward himself (herself). The security of this tip-to-tip pinch can be enhanced by grasping the suture ends between the tips of the long fingers.22 Once there is meticulous approximation of wound edges. the surgeon must detach the needle from the fixed suture end before a two-hand tie. The suture end (white) farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch). it is important to point out that the fixed end of the suture is being passed through the suture loops in the two-hand ties. the slip knot can be converted to a square knot. The tying of square. small fingers. ring fingers. The surgeon is standing facing the wound from the bottom of each illustration. The free end of the suture is white to facilitate illustration of the knot tying technique. the fixed end (black) of the suture with its attached needle enters the farther side of the mid-portion of the wound and exits from the side of the wound closer to the surgeon. The technique of tying slip knots has been included in the manual because it is an excellent method to approximate temporarily the edges of wounds subjected to strong tensions In fact. A standard format for illustrating surgical knot tying techniques has been used throughout the manual (Figure 9). Because the wound edges are subjected to static tensions. and the palm of each hand (grip activity). The grasped fingers apply constant tension to the suture ends. Consequently. Most of the knot tying techniques in this manual comply with these recommendations. A horizontal incision is pictured in the top of each illustration.

Construct a secure knot that cannot be can be advanced to the wound edge. 4. between the suture “ears” during knot 3. encircled by the suture loop. construct a knot security. advanced to the wound edges. 5. Construct a two-throw square knot that 2. 2. Once meticulous apposition of the the required number of throws for wound edges is achieved. 44 . Approximate the edges of the divided construction that damage the suture and tissue without strangulating the tissue reduce its strength. VII. essential elements DO DON’T 1. rather than by slippage. Pass the surgical needle swaged to a 1. Position your hands on each side and parallel to the suture loop. Position your hands perpendicular to throws that allow it to fail by breakage the suture loop. direction away from you. Pass the surgical needle swaged to a suture through the wound edges in a suture through the wound edge in a direction toward you. Add further throws to a knot that has 4. providing a preview of the ultimate 3. knot that has has sufficient number of 5. Apply frictional forces (sawing) apposition of the wound edges.

Apply constant force slowly to the 9. needle holder parallel to the wound. 7. Position the needle holder above the 11. reverse the position of hands after each additional throw. Position the needle holder above the fixed suture end to form the first fixed suture end to form the first and throw. maintain continuous tension of the 9.DO DON’T 6. Clamp the suture loop with an instru- during the instrument tie. After each throw. wound surface. 11. Apply opposing forces to the knot 6. maintain continuous tension on suture 10. 8. Use the one-hand tie technique to “ears” of each throw of the knot. ment because it will crush the suture. Clamp only the free end of the suture 12. position the ends.30-32 45 . During an instrument tie. During an instrument tie. Exert unequal levels of tension to the “ears” that are equal in magnitude suture ends that convert the knot into and in a plane parallel to that of the a slip knot. square knot (1=1). 12. needle holder perpendicular to the 10. reducing its strength. your hands that apply tension to the 8. and then below the fixed suture second suture throws of a square end to form the second throw of the (1=1) knot. “ears” of each throw of the knot. Use the two-hand tie technique to suture ends. Maintain the same position of your 7. Apply a constant force rapidly to the suture ends. position the wound.

The grasped fingers apply constant tension to the suture ends. Hold Suture Ends The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch). The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers. small fingers and the palm of each hand (grip activity). while the tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. two-hand tie techniques — SQUARE KNOT (1=1) formation of the first throw Step 1. VIII. 46 . ring fingers.

by the right hand. Pass Thumb Up Through the Suture Loop The tip of the left thumb advances up through the suture loop. replacing the tip of the left index finger. As the tip of the left index finger The free suture end. Form the First Suture Loop Pass Free The first loop is formed by the tip of the Suture End left index finger that passes its suture end Over the over the other suture end held by the right Suture Loop hand. 47 . Step 4. passes its suture end over the suture end held by the right hand. the left thumb is passed over (arrow) passes under (arrow) the suture end held the suture loop. Step 3. Step 2. held by the right hand.

48 . The free suture end is regrasped between the tips of the right thumb and index finger to withdraw (arrow) it through the suture loop to form a single-wrap throw. The right hand releases its free suture end so that it can be passed down through the suture loop. VIII. Pass Free Suture End Down Through the Suture Loop to Form Single-Wrap Throw After the suture end is grasped between the tips of the left thumb and index finger. the pinched suture end is passed downward through the suture loop. two-hand tie techniques — SQUARE KNOT (1=1) formation of the first throw (cont’d) Step 5.

49 . Advancement of the first throw is complete when the divided skin edges of the mid-portion of the wound are approximated. The surgeon applies constant tension to the suture ends. Advance First Single-Wrap Throw to Wound Surface With the suture ends grasped in the palms of the surgeon’s hands. the tips of the index fingers and thumbs position the suture ends in a direction (arrows) perpendicular to that of the wound.Step 6. which advances the first single-wrap throw of the square knot to the surface of the wound.

Begin Formation of the Second Suture Loop The dorsum of the tip of the left thumb is passed under its suture end in order to direct it beneath (arrow) the other suture end that is held by the right hand. two-hand tie techniques — SQUARE KNOT (1=1) formation of the second throw Step 7. constant tension is applied to the suture ends to maintain wound approximation. VIII. 50 . During formation of the second throw.

passed under the suture loop to be positioned (arrow) between the tips of the left index finger and thumb. Step 9. Form the Second Suture Loop Pass Free Suture End The left thumb advances its suture end beneath Under the Suture Loop the other suture end to form a suture loop. 51 . Step 10. Pass Index Finger Down Through the Suture Loop After the tip of the left index finger contacts the tip of the left thumb (tip- to-tip pinch). The free suture end held The tip of the left index finger passes down by the right hand is (arrow) to touch the left thumb. Step 8. both are advanced down (arrow) through the suture loop so that only the tip of the left index finger remains in the loop.

The right hand releases its free suture end to allow its passage through the suture loop. VIII. Single-Wrap Throw The free suture end grasped between the tips of the left thumb and index finger is advanced upward through the suture loop. after which it regrasps the free suture end to withdraw (arrow) through the suture loop. Pass Free Suture End Up Through the Suture Loop to Form Second. 52 . two-hand tie techniques — SQUARE KNOT (1=1) formation of the second throw (cont’d) Step 11.

Advance Square Knot (1=1) to Wound Surface The second throw is advanced and set against the first throw by applying tension in a direction (arrows) perpendicular to that of the wound. Advancement of the second throw is complete when the second throw contacts the first throw to form a square (1=1) knot. the surgeon will construct a knot with a sufficient number of throws and 3mm cut “ears” so that knot security is determined by knot breakage. Once exact approximation of the wound edges is accomplished. Ideally. square knot to allow meticulous approximation of the wound edges.3 53 .Step 12. rather than by slippage. the surgeon should be able to advance the two-throw.

two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1) formation of the first. The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers. VIII. 54 . small fingers and the palm of each hand (grip activity). while the tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. ring fingers. Hold Suture Ends The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch). double-wrap throw Step 1. The grasped fingers apply constant tension to the suture ends.

thumb passes under (arrow) the suture end held is passed over (arrow) by the right hand. 55 . replacing the tip of the left index finger. the left held by the right hand. Form the First Suture Loop Pass Free The first suture loop is formed by the tip of the Suture End left index finger that passes its suture end over the Over the other suture end held by the right hand. Step 4. As the Suture Loop tip of the left index finger passes its suture end The free suture end. Step 2. the suture loop. over the suture end held by the right hand. 1. Pass Thumb Up Through the Suture Loop The tip of the left thumb advances up through the suture loop. Introduction Step 3.

56 . two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1) formation of the first. The tips of the right thumb and index finger regrasp the free suture end to withdraw (arrow) it through the suture loop to form a single-wrap throw. The right hand releases its free suture end so that it can be passed through the loop. VIII. the pinched suture end is passed downward through the suture loop. Pass Free Suture End Down Through the Suture Loop to Form Single-Wrap Throw After the free suture end is grasped between the tips of the left thumb and index finger. double-wrap throw (cont’d) Step 5.

Step 6. Pass Left Thumb Up Into the Suture Loop The left thumb passes up (arrow) through the suture loop. Step 8. Step 7. replacing the left index finger in preparation for the formation of the double-wrap first throw. Maintain Suture Loop with Left Index Finger Pass Free Suture End The rectangular configuration of the suture Over the Suture Loop loop is maintained by keeping the tip of The free suture end the index finger (arrow) in the suture loop. held by the right hand is passed over (arrow) the suture loop and grasped between the tips of the left thumb and index finger. 57 .

two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1) formation of the first. VIII. The right hand releases its suture end so that it can be withdrawn through the suture loop. double-wrap throw (cont’d) Step 9. 58 . First Throw The free suture end grasped between the tips of the left thumb and index finger is passed down (arrow) through the suture loop. it is regrasped by the right hand to withdraw it through the suture loop. As the free suture end passes through the loop. Pass Free Suture End Down Through the Suture Loop to Form Double-Wrap.

first throw of the surgeon’s knot square to the surface of the wound. Advance Double-Wrap. The surgeon applies constant tension to the suture ends. Advancement of the first throw is complete when the divided edges of the mid-portion of the wound are approximated.Step 10. which advances the double-wrap. 59 . the tips of the index fingers and thumbs position the suture ends in a direction (arrows) perpendicular to that of the wound. First Throw to Wound Surface With the suture ends grasped in the palms of the surgeon’s hands.

two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1) formation of the second throw Step 11. 60 . constant tension is applied to the suture ends to maintain wound approximation. VIII. Begin Formation of the Second Suture Loop The dorsum of the tip of the left thumb is passed under (arrow) its suture end in order to direct it beneath the other suture end that is held by the right hand. During formation of the second throw.

The tip of the left index by the right hand is passed finger passes down (arrow) to touch under the suture loop to the left thumb. both are advanced down (arrow) through the suture loop so that only the tip of the left index finger remains in the suture loop. be positioned (arrow) between the tips of the left index finger and thumb. Step 13. Form the Second Suture Loop Pass Free Suture End The left thumb advances its suture end Under the Suture Loop beneath the other suture end to form The free suture end held a suture loop. Step 12. Pass Index Finger Down Through Suture Loop After the tip of the left index finger contacts the tip of the left thumb (tip- to-tip pinch). Step 14. 61 .

after which it regrasps the free suture end to withdraw (arrow) it through the suture loop. two-hand tie techniques — SURGEON’S KNOT SQUARE (2=1) formation of the second throw (cont’d) Step 15. 62 . The right hand releases its free suture end to allow its passage through the suture loop. Pass Free Suture End Up Through the Suture Loop To Form Single-Wrap Throw The free suture end grasped between the tips of the left thumb and index finger is advanced upward though the suture loop. VIII.

Step 16. rather than by slippage. Advance Surgeon’s Knot Square (2=1) to Wound Surface The single-wrap throw is advanced and set against the first double-wrap throw by applying tension in a direction (arrows) perpendicular to that of the wound. The direction of the tension applied to the suture ends of the first throw is opposite to that exerted on the suture ends of the second throw. the surgeon will construct a knot with a sufficient number of throws and 3mm cut “ears” so that knot security is determined by knot breakage.3 63 . Advancement of the second throw is complete when the second throw contacts the first throw to form a surgeon’s knot square (2=1). Once exact approximation of the wound edges is accomplished.

The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers. 64 . The grasped fingers apply constant tension to the suture ends. Hold Suture Ends The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip- to-tip pinch). while the tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. two-hand tie techniques — SLIP KNOT (S=S) formation of the first throw Step 1. ring fingers. small fingers and the palm of each hand (grip activity). VIII.

Step 3. the right hand. 65 . Step 4. held the other suture end held by the right by the right hand. the left thumb passes under (arrow) the suture end held by the right hand. As the tip of the left index finger passes over (arrow) the suture its suture end over the suture end held by loop. Pass Thumb Up Through the Suture Loop The tip of the left thumb advances up through the suture loop. is passed hand. Step 2. Form the First Suture Loop Pass Free Suture End Over The first suture loop is formed by the tip of the Suture Loop the left index finger that passes its suture end over The free suture end. replacing the tip of the left index finger.

The free suture end is regrasped between the tips of the right thumb and index finger to withdraw (arrow) it through the suture loop. VIII. 66 . the pinched suture end is passed downward through the suture loop. The right hand releases its free suture end so that it can be passed down through the suture loop. two-hand tie techniques — SLIP KNOT (S=S) formation of the first throw (cont’d) Step 5. Pass Free Suture End Down Through the Suture Loop After the suture end is grasped between the tips of the left thumb and index finger.

the divided skin edges of the mid-portion of the wound are approximated. Apply Tension to the Straight.Step 6. Taut Suture End Advance First Throw The first throw of the slip knot is completed to Wound by first applying tension (arrow) to the suture The tip of the right index finger slides (arrow) held by the left hand causing the suture end the loop along the straight. taut suture end held to be straight and taut. The suture end held by the left hand until the loop contacts the wound. 67 . by the right hand forms a loop around the Advancement of the first throw is complete when straight. taut suture held by the left hand. Step 7.

68 . constant tension is applied to the suture ends to maintain wound approximation. Begin Formation of Second Suture Loop The dorsum of the tip of the left thumb is passed under its suture end in order to direct it beneath (arrow) the other suture end that is held by the right hand. During formation of the second throw. VIII. two-hand tie techniques — SLIP KNOT (S=S) formation of the second throw Step 8.

Pass Index Finger Down Through the Suture Loop After the tip of the left index finger contacts the tip of the left thumb (tip- to-tip pinch). Step 9. Suture Loop The tip of the left index finger passes down The free suture end held (arrow) to touch the left thumb. Step 10. Form the Second Suture Loop Pass Free Suture The left thumb advances its suture end beneath End Under the the other suture end to form a suture loop. 69 . Step 11. by the right hand is passed under the suture loop to be positioned (arrow) between the tips of the left index finger and thumb. both are advanced down (arrow) through the suture loop so that only the tip of the left index finger remains in the suture loop.

after which it regrasps the free suture end to withdraw (arrow) it through the suture loop. two-hand tie techniques — SLIP KNOT (S=S) formation of the second throw (cont’d) Step 12. VIII. The right hand releases its free suture end to allows its passage through the suture loop. Pass Free Suture End Up Through the Suture Loop The free suture end grasped between the tips of the left thumb and index finger is advanced upward through the suture loop. 70 .

by the right hand. (Insert) The square knot can be converted to a slip knot by applying tension primarily to one suture end.Step 13. Taut Suture End Advance Slip Knot (S=S) to Wound Surface to Form Second Throw The tip of the right index finger slides (arrow) The tension applied (arrow) to the suture end this second throw against the first throw. taut suture end held by by applying tension to the suture end held the left hand. while the left to become straight and taut. Step 14. 71 . The suture end hand maintains tension (arrow) on its suture held by the right hand forms a second loop end. Apply Tension to the Straight. held by the left hand causes this suture end completing the slip knot (S=S). The slip knot will become a square knot around the straight.

while the tips of the distal phalanges of the right thumb and index finger grasp the suture end exiting from the closer side of the wound. small fingers and the palm of each hand (grip activity). ring fingers. one-hand tie technique — SQUARE KNOT (1=1) formation of the first throw Step 1. IX. 72 . Hold Suture Ends The suture end exiting from the side of the wound farther from the surgeon is grasped between the tips of the distal phalanges of the left thumb and index finger (tip-to-tip pinch). The security of this tip-to-tip pinch of the suture ends can be enhanced by grasping the suture ends between the tips of the long fingers. The grasped fingers apply constant tension to the suture ends.

knot construction (arrow) of the free suture end up through the can be safely accomplished without detaching suture loop. continues until the dorsal surface of its distal The tip of the left index finger begins to flex phalanx contacts the free suture end held by the around (arrow) the fixed suture end held by the left hand. 73 . Form the First Suture Loop Pass Index Finger Down into The first throw of the square knot is initiated by The Suture Loop the tip of the left index finger that passes its free As the index finger passes into the suture loop. Consequently. suture loop and passes the free suture end through extension of the finger will begin withdrawal the suture loop. After the free suture end rests on the right hand. the needle from the fixed suture end. suture end over the fixed suture end held between flexion of the tip of the left index finger the tips of the right index finger and thumb. Note that the left hand forms the dorsal surface of the tip of the left index finger.Step 2. Step 3.

IX. 74 . Begin Withdrawal of Free Suture End Up Through the Suture Loop Extension of the distal phalanx of the left index finger brings the suture end held by the left hand upward (arrow) through the loop. one-hand tie technique — SQUARE KNOT (1=1) formation of the first throw (cont’d) Step 4.

The surgeon on the first throw. which loop to widen. During this fingers position the suture ends in a direction (arrows) interval. the tips of the thumbs and index must release its grip of the suture. Advancement of the first throw is complete when the divided skin edges of the mid-portion of the wound are approximated. Pass Free Suture End Up Through Advance First Single-Wrap Throw the Suture Loop to Wound Surface For the left index finger to bring the entire suture With the suture ends grasped in the palms of the end up (arrow) through the loop.Step 5. with subsequent partial separation advances the first. the left hand surgeon’s hands. single-wrap throw of the square of the wound edges. Step 6. tension cannot be maintained continually perpendicular to that of the wound. 75 . allowing the first-throw suture applies constant tension to the suture ends. knot to the surface of the wound.

the surgeon supinates the left wrist so that the free suture end is positioned over the tips of the long. Begin Formation of the Second Suture Loop While grasping the suture end exiting from the farther side of the wound between the tips of the left thumb and index finger. 76 . ring and small fingers. one-hand tie technique — SQUARE KNOT (1=1) formation of the second throw Step 7. IX.

Step 9.Step 8. to pass beneath the free suture end held between the tips of the left thumb and index finger. Form the Second Suture Loop Flex Long Finger Toward the With continued supination of the wrist. the Free Suture End tips of the left long and ring fingers advance Continued flexion (arrow) of the distal phalanx their free suture end under the suture end of the left long finger allows the tip of the finger held by the right hand to form a suture loop. 77 .

For the left long finger to withdraw the entire free suture end down through the loop. allowing the first-throw. extension of the distal phalanx of the long finger begins to withdraw (arrow) the suture end down through the loop. Begin Withdrawal of the Free Suture End Down Through the Suture Loop Once the dorsum of the distal phalanx of the left long finger is beneath the free suture end held between the tips of the left thumb and index finger. the left thumb and index finger must release their grip of the suture. IX. 78 . one-hand tie technique — SQUARE KNOT (1=1) formation of the second throw (cont’d) Step 10. During this interval. suture loop to widen with subse- quent partial separation of the wound edges. tension cannot be maintained continually on the first throw.

79 . it is held loosely between the tips of the left long when the second throw contacts the first throw to form a square and ring fingers. Complete Withdrawal of the Free Suture End Down Advance Square Knot (1=1) to Wound Surface Through the Suture Loop to Form Second. rather than by slippage. the surgeon will construct a knot with a sufficient suture end. square knot to allow meticulous approximation of the the radial side of the distal phalanx of the left ring finger wound edges.Step 11. This loose grasp (key pinch) between the (1=1) knot.3 the left thumb and index finger must release the suture. the tips of determined by knot breakage. Advancement of the second throw is complete the loop. Step 12. Ideally. the surgeon should be able to advance the ulnar side of the distal phalanx of the left long finger and two-throw. The second throw is advanced and set against the first throw by Single-Wrap Throw applying tension in a direction (arrows) perpendicular to that During withdrawal (arrow) of the free suture end through of the wound. Once exact approximation of the wound edges is does not allow constant tension to be maintained on this accomplished. For the left long and ring fingers to withdraw number of throws and 3mm cut “ears” so that knot security is (arrow) the entire suture end through the loop.

it is easy to form (arrow) suture loops as well as to save suture material. X. instrument-tie technique — SQUARE KNOT (1=1) formation of the first throw (cont’d) Step 1. The needle holder is positioned perpendicular to and above the fixed suture end. Because the needle holder passes the free suture end through the suture loop. By keeping the length of the free suture end relatively short (<2 cm). Position the Needle Holder The instrument tie is performed with a needle holder held in the surgeon’s right hand. 80 . knot construction can be safely accomplished without detaching the needle from the fixed suture end. The left hand holds the fixed suture end between the tips of the thumb and index finger.

(If the suture is wrapped twice around the needle holder jaws. first throw displays a greater resistance to slippage than a single- wrap throw. 81 . double-wrap throw of the surgeon’s knot square will be formed. accounting for its frequent use in instrument ties in wounds subjected to strong.Step 2. Form the First Suture Loop The fixed suture end held by the left hand is wrapped over and around the needle holder jaws to form the first suture loop. A double-wrap. the first. static skin tensions).

instrument-tie technique — SQUARE KNOT (1=1) formation of the first throw (cont’d) Step 3. X. Single-Wrap Throw The tips of the needle holder jaws grasp the suture end and withdraw (arrow) it through the first suture loop. Clamp Free Suture End And Withdraw it Through the Suture Loop to Form the First. The resulting first throw will have a figure “8” shape. 82 .

83 . Once the first throw of the square knot contacts the skin. the edges of the mid-portion of the wound are approximated.Step 4. This single- wrap throw is advanced to the wound surface by applying tension in a direction (arrows) that is perpendicular to that of the wound. The left hand moves away from the surgeon. Advance the First Single-Wrap Throw to Wound Surface The figure “8” shape throw will be converted into a rectangular-shaped throw by reversing the direction of the hand movement. while the needle holder held in the right hand advances toward the surgeon.

If the surgeon were to place the needle holder beneath the fixed suture end. 84 . Position the Needle Holder The needle holder releases the free suture end. The right hand holding the needle holder moves away from the surgeon to be positioned perpendicular to and above the fixed suture end. the ultimate knot construction would be a granny knot (1x1). X. A second throw will be formed by the left hand as it wraps the fixed suture end over and around (arrow) the needle holder jaws. instrument-tie technique — SQUARE KNOT (1=1) formation of the second throw Step 5.

Form the Second Suture Loop The fixed suture end held by the left hand is wrapped over and around the needle holder to form the second suture loop. 85 .Step 6. With the suture wrapped around the needle holder jaws. the needle holder is moved to grasp the free suture end. after which it is withdrawn through the suture loop.

By withdrawing the free suture end through the loop. instrument-tie technique — SQUARE KNOT (1=1) formation of the second throw (cont’d) Step 7. Clamp Suture End and Withdraw it Through the Suture Loop to Form the Second. Single-Wrap Throw The tips of the needle holder jaws grasp the free suture end and withdraw (arrow) it through the second suture loop. 86 . a rectangular-shaped second throw is formed. X. The surgeon will apply tension to the suture ends in a direction perpendicular to that of the wound.

Step 8. square knot (1=1) to allow meticulous approximation of the wound edges. with a sufficient number of throws and 3mm cut “ears” so that knot security is determined by knot breakage. rather than by slippage. Advancement of the second throw is complete when the second throw contacts the first throw and forms a square knot. the surgeon should be able to advance the two-throw. the surgeon will construct a knot using this instrument technique.3 87 . Once exact approximation of the wound edges is accomplished. Ideally. Advance Square Knot (1=1) to Wound Surface The second throw is advanced and set against the first throw by applying tension to the suture ends in a direction (arrows) perpendicular to that of the wound.

Performance characteristics of the suture and needle products produced by Covidien were judged by clinically acceptable and nonacceptable ratings.1% had clinical acceptable ratings for the 25.545 suture and needle products evaluated. Of these suture and needle products. this rigorous suture and needle performance evaluation confirms the high level of performance of the suture and needle products made by Covidien. the surgeons found that 98. suture and needle products made by Covidien (formerly Tyco Healthcare Group LP. selection of suture and needle products On the basis of the largest multicentric evaluation of suture and needle products reported. (Rolling Meadows. IL). Inc. While the study coordinated by Consortia Inc.545 suture and needle products. Norwalk. provides important guidelines for judging the clinical acceptability of suture and needle products in a hospital setting.33 In this multicentric evaluation of suture and needle products conducted by Consorta. 88 . CT) received an extremely high acceptability rating by the surgeons. XI. 42 shareholder hospitals enrolled 1913 surgeons to participate in this nonexperimental observational study of the clinical performance of 25.

C. Caprosyn™. E. Shimer AL. Rodeheaver PE.11(1-2):41-54. J Long Term Eff Med Implants 2001.14(5):359-368. Rodeheaver PA. Boyd LM. Rodeheaver GT. Szarmach RR. Rodeheaver GT. Livingston J. Pineros-Fernandez A. Thacker JG.com/syneture. Drake DB. A.covidien.14(3):251-259. 89 .com/syneture A complete copy of this study can be found at www. An innovative absorbable coating for the polybutester suture. Drake DB. Edlich RF Rodeheaver GT. Rodeheaver GT.12(4):211-229. Edlich RF. D. Drake DB. full text scientific articles available at www. Szarmach RR. An expanded surgical suture and needle evaluation and selection program by a healthcare resource management group purchasing organization. J Long Term Eff Med Implants 2005.covidien.13(3):155-170. another major advance in synthetic monofilament absorbable suture. Experimental studies in swine for measurement of suture extrusion. J Long Term Eff Med Implants 2002. Edlich RF. XII. J Long Term Eff Med Implants 2003. Livingston J. Edlich RE. Moody DL. An innovative surgical suture and needle evaluation and selection program. B. J Long Term Eff Med Implants 2004. Edlich RF.

Physical and chemical configuration of sutures in the development of surgical infection. Graumont R.. N. 1943. 90 . Ann Surg 1973 Jun. Trimbos JB. Edlich RF.82(3):390-393. Edgerton MT.171:892-898. Postlethwait RW.177(6):679-688. Cornell Maritime Press. Thacker JG. Thacker JG.204:193-199. XIII. Edlich RF. Ann Surg 1986. 3. 2. Br J Surg 1965. Hensel J: Encyclopedia of knots and fancy rope work. Kurtz L. Edgerton MT. Smeets M.13(1):1-10. 6. references 1. McGregor W. Hermans J. Mechanical Performance of sutures in surgery Am J Surg 1977. Edlich RF. Hill LG. Reducing accidental injuries during surgery. Rodeheaver GT. a dynamic suture for wound closure. Panek PH. Verdel M. 8. Kurtz LD. Turnbull VG. 9. 4. Long-term comparative study of non-absorbable sutures. Security of various knots commonly used in surgical practice. Obstet Gynecol 1984. Nesbit WS. 5. Cosmetic result of lower midline laparotomy wounds: polybutester and nylon skin suture in a randomized clinical trial.Y. Rodeheaver G. Edlich RF. Haxton H: The influence of suture materials and methods on the healing of abdominal wounds. Ann Surg 1970. J Long Term Eff Implant 2003. Trimbos JB. 7.52:372-375. Rodeheaver GT. pp 3-10.133:713-715.64:274-280. Novafil. Wind TC. Obstet Gynecol 1993.

11. Rodeheaver GT. Gordon S. Relationship of cellular enzyme activity to catgut and collagen suture absorption. Drake DB. J Long Term Effects Med Implants 2004. Watkins FH. Edlich RF. Biomechanical performance of a braided absorbable suture. 12. Thacker JG. Cavalcanti ET.129:691-696. Rodeheaver GT. J Long Term Effects Med Implants 2001. Edlich RF.11 (1 & 2):41-54. Surg Gynecol Obstet 1981. Rodeheaver PE. Surg Gynecol Obstet 1981. A new synthetic monofilament absorbable suture made from polytrimethylene carbonate. de Quevedo AS. Williams JA. Lins AJ. 17. An innovative absorbable coating for the polybutester suture. Edlich RF. Drake DB. Pinheiro AL. Green CW. Willigan DA. 13. de Castro JF.6:181-196. Stiles BM. 91 . Katz AR. Kaganov AL.10. Rego TI. Faulkner BC. Mazzarese PM. Traeland H. Gear AJ. Brown HC.8(1):21-25. Edlich RF. 16. Rodeheaver GT. Thiers FA.14(3):251-259. Rodeheaver GT. Stanimir GW. J Long Term Effects Med Implants 1996. Hellewell TB. Fried GM.6:169-179. J Long Term Effects Med Implants 1996. Shimer AL. Using Novafil: would it make suturing easier? Braz Dent J 1997. 15. Aca CR. Mechanical performance of polyglycolic acid and polyglactin 910 synthetic absorbable sutures. Biomechanical and clinical performance of a new synthetic monofilament suture. Mukherjee DP. Edlich RF. 14. Boyd LM.161:213-222. Experimental studies in swine for measurement of suture extrusion. Salthouse TN. Surg Gynecol Obstet 1985. Beltran KA.153:835-841. Faulkner BC.

Rodeheaver GT. Am J Surg 1975. Powell DM. references (cont’d) 18.14(5):359-368. Thacker JG. Unique performance characteristics of Novafil®. XIII. Edgerton MT. Moore JW. A model study.107:458-468. Bellian KT. Influence of knot configuration and tying technique on the mechanical performance of sutures. Moody DL. Thacker JG. 15: 351-356. Technical considerations in knot construction. Taylor FW: Surgical knots. Ann Surg 1938. Kurtz L. Rodeheaver PA. Drake DB. CAPROSYN™. Åberg C. Annuziata CC.142:1-7. Drake DB. Thacker JG. Borzelleca DC. Edlich RF. Continuous percutaneous and dermal suture closure. Rodeheaver GT. 23. Edlich RF: Mechanical performance of surgical sutures. 24. Kauzlarich JJ. Rodeheaver GT. Edlich RF Rodeheaver GT. Edlich RF. Holmlund DE.130:374-380. Woods JA. Knot properties of surgical suture materials. Rodeheaver GT. 20. J Long Term Eff Med Implants 2005. 19. 25.140:355-362. Becker DG. Tensile strength of twelve types of knot employed in surgery. 21. another major advance in synthetic monofilament absorbable suture. using different suture materials. Tera H. Edlich RF. Zimmer CA. 22.142:230-360. J Emerg Med 1997. J Emerg Med 1991. Pineros-Fernandez A. Surg Gynecol Obstet 1987.9:107-113. Acta Chir Scand 1974. Part I. Acta Chir Scand 1976. Gear AJL. 92 .

Stamp CV. Rodeheaver GT. Thacker JG. Am J Surg 1989. Surgical needle holder damage to sutures. J Long Term Effects Med Implants 2003. Towler MA. Howes EL. 31. Tissue strength of the healing wound in relation to the holding strength of the catgut suture. 27.124:665-668. Åberg C. N Engl J Med 1929. Tera H. New atraumatic rounded-edge surgical needle holder jaws. 33. Nichols WK. Thacker JG. Edlich RF. 29. Towler MA. Edlich RE. McGregor W.54:300-306.13(3):155-170. Edlich RF. Arch Surg 1989. Abidin MR. Surgical manipulation and the tensile strength of polypropylene sutures. 30. An expanded surgical suture and needle evaluation and selection program by a healthcare resource management group purchasing organization.26. Surgery 1980. Silver D.157:241-242.200:1285-1290. 28. Nochimson GD. Anastomotic aneurysms following lower extremity revascularization.142:429-432. Change in strength of aponeurotic tissue enclosed in the suture during the initial healing period. Harvey SC. McGregor W. Åberg C. Livingston J. N Engl J Med 1929. An Experimental investigation in rabbits. 200:1285-1290. Acta Chir Scand 1976. 32. Am Surg 1988. Keitzer WF. Szarmach RR. Dobrin PB. Stanton M.88:366-374. 93 . The strength of the healing wound in relation to the holding strength of the catgut suture.

Jill Amanda Greene for all their innovative work in getting this book completed. Michael Lobasz. Charlottesville. as well as the extremely talented pre-medical student. This manual was illustrated by: Craig A. Dayna Woode and the dynamic Nursing Student. Luce. MS. Amy Cochran. the creative research assistant. Acknowledgements: We would like to acknowledge the gifted talents of Graphic Designer. VA .

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